State Insurance Mandates for Autism Spectrum Disorder

States With Specific Autism Mandates

The following states have specific autism mandates, which require certain insurers to provide coverage for autism spectrum disorder. (Certain insurance plans are exempt from state mandates. Please contact your plan administrator to see if your plan includes state mandated autism spectrum disorder benefits.)

Alabama

Requires a health benefit plan to provide coverage for the screening, diagnosis and treatment of autism spectrum disorder for individuals age eighteen or under in policies and contracts to employers with at least 51 employees for at least 50 percent of its working days for the preceding calendar year. Coverage is limited to treatment that is prescribed by the insured's licensed physician or licensed psychologist and includes: behavioral health treatment, pharmacy care, psychiatric care, psychological care, and therapeutic care (which includes services provided by a licensed and certified speech therapist).

Alaska

Requires certain insurers to provide coverage for the diagnosis and treatment of autism spectrum disorder for individuals under 21 effective January 1, 2013. Covered treatment includes medically necessary pharmacy care, psychiatric care, psychological care, habilitative or rehabilitative care, and therapeutic care (which includes services provided by a licensed speech-language pathologist.) There is no limit on the number of visits an individual may make to an autism services provider.

Arizona

Note: Speech language services are not clearly defined in the statue. However, behavioral therapy is specifically defined as applied behavioral analysis and coverage limitations for behavioral therapy are set out.

California

Requires all health care service plan contract that provides hospital, medical, or surgical coverage to provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. Treatments include: professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or
restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and includes speech-language pathology and audiology.

Connecticut

Requires each group health insurance policy to provide coverage for the diagnosis and treatment of autism spectrum disorders. Treatments include: behavioral therapy; prescription drugs; direct psychiatric or consultative services provided by a licensed psychiatrist; direct psychological or consultative services provided by a licensed psychologist; physical therapy provided by a licensed physical therapist; speech and language pathology services provided by a licensed speech and language pathologist; and occupational therapy provided by a licensed occupational therapist, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with an autism spectrum disorder.

Delaware

Requires all health benefit plans to provide coverage for the screening and diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders in individuals less than 21 years of age. Treatment includes: behavioral health treatment; pharmacy care; psychiatric care; psychological care; therapeutic care (including services provided by a speech, occupational, or physical therapists or an aide or assistant under their supervision); items and equipment necessary to provide, receive, or advance in the above listed services, including those necessary for applied behavioral analysis; and any care for individuals with autism spectrum disorders that is determined by the Secretary of the Department of Health and Social Services, based upon their review of best practices and/or evidence-based research, to be medically necessary.

Coverage under this section shall not be denied on the basis that the treatment is habilitative or nonrestorative in nature.

Coverage for the services shall be limited to $36,000 annually and may not exceed $200,000 in total lifetime benefits for an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developmental disability at 8 years of age or younger.

Georgia

Requires accident and sickness contracts, policies or benefit plans to provide for medically necessary coverage for autism spectrum disorder for children under six years of age. Coverage includes therapy services provided by a licensed or certified speech therapist or speech-language pathologist.

Hawaii

Requires individual or group accident and health or sickness insurance policies issued January 1, 2016, to provide coverage for individuals under fourteen for the diagnosis and treatment of autism. Coverage includes behavioral health treatment, pharmacy care, psychiatric care, psychological care and therapeutic care, including therapy services provided by a licensed speech pathologists.

Illinois

Requires certain health insurers to provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders. Treatment includes the following care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder by (A) a physician licensed to practice medicine in all its branches, or (B) a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches; psychiatric care, meaning direct, consultative, or diagnostic services provided by a licensed psychiatrist; psychological care, meaning direct or consultative services provided by a licensed psychologist; habilitative or rehabilitative care, meaning professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are intended to develop, maintain, and restore the functioning of an individual; therapeutic care, including behavioral, speech, occupational, and physical therapies. Coverage provided shall be subject to a maximum benefit of $36,000 per year, but shall not be subject to any limits on the number of visits to a service provider.

Indiana

Requires group and individual policies to provide coverage for the treatment of a pervasive developmental disorder of an insured. A pervasive developmental disorder is defined as a neurological condition, including Asperger's syndrome and autism, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. The coverage required may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the accident and sickness insurance policy.

Note: Speech language services are not specifically defined in the statute. Coverage is "limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan."

Iowa

Requires a group plan established for employees of the state providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide coverage benefits to covered individuals under twenty-one years of age for the diagnostic assessment of autism spectrum disorders and for the treatment of autism spectrum disorders. Treatment includes medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care, and therapeutic care (including services provided by a licensed speech pathologist, licensed occupational therapist, or licensed physical therapist). Coverage shall not exceed thirty-six thousand dollars per year but shall not be subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorders.

Kansas

Effective January 1, 2011, requires the state employees' health care commission to provide for the coverage of services for the diagnosis and treatment of autism spectrum disorder in any covered individual whose age is less than 19 years. Coverage is determined in consultation with the autism services provider and the patient. Coverage for benefits for any covered person diagnosed with one or more autism spectrum disorders and whose age is between birth and less than seven years shall not exceed $36,000 per year. Coverage for benefits for any covered person diagnosed with one or more autism spectrum disorders and whose age is at least seven years and less than 19 years shall not exceed $27,000 per year.

Effective January 1, 2015, requires any large group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides coverage for accident and health services and which is delivered, issued for delivery, amended or renewed to provide coverage for the diagnosis and treatment of autism spectrum disorder in any covered individual whose age is less than 12 years.

Note: Speech language services are not clearly defined in the statue. However, behavioral therapy is specifically defined as applied behavioral analysis and coverage limitations for behavioral therapy are set out.

Kentucky

Requires that a large group health benefit plan and individual and small group market health benefit plans provide coverage for the diagnosis and treatment of autism spectrum disorders.

Large group health benefit plan

Treatment includes: medical care; habilitative or rehabilitative care; pharmacy care, if covered by the plan; psychiatric care; psychological care; therapeutic care (includes services provided by licensed speech therapists, occupational therapists, or physical therapists); and applied behavior analysis prescribed or ordered by a licensed health or allied health professional. Coverage under this section shall be subject to a maximum annual benefit per covered individual as follows: for individuals between the ages of one (1) through their seventh birthday, the maximum annual benefit shall be $50,000 per individual; for individuals between the ages of seven (7) through 21, the maximum benefit shall be $1,000, per month per individual.

Louisiana

Requires any health coverage plan to provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals less than 21 years of age. Treatment includes: habilitative or rehabilitative care; pharmacy care; psychiatric care; psychological care; therapeutic care (including services provided by licensed or certified speech therapists, occupational therapists, or physical therapists licensed or certified in this state), provided the care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a physician or psychologist who shall be licensed in this state and who shall supervise provision of such care. Coverage shall be subject to a maximum benefit of $36,000 per year and a lifetime maximum benefit of $144,000. There shall not be any limits on the number of visits an individual may make to an autism services provider.

Maine

Requires all individual and group health insurance policies and contracts must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 5 years of age or under in accordance with the following. Treatment includes: habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services; counseling services provided by a licensed psychiatrist, psychologist, clinical professional counselor or clinical social worker; and therapy services provided by a licensed or certified speech therapist, occupational therapist or physical therapist.

Maryland

Requires insurers and nonprofit health service plans and health maintenance organizations to provide coverage for habilitative services to children under the age of 19 years coverage who have a congenital or genetic birth defect (including autism).

Massachusetts

Effective January 1, 2011, requires insurance coverage for autism. Treatment includes the following care prescribed, provided or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: habilitative or rehabilitative care; pharmacy care; psychiatric care; psychological care; and therapeutic care, including speech therapy services. Certain insurers may be exempt from requirements for 3 years.

Michigan

Effective January 1, 2014, requires a health care corporation group or nongroup certificate to provide coverage for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders. Treatment of autism spectrum disorders prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist includes: (i) Behavioral health treatment; (ii) Pharmacy care; (iii) Psychiatric care; (iv) Psychological care; and (v) Therapeutic care (including services provided by a licensed or certified speech therapist, occupational therapist, physical therapist, or social worker.) Coverage for treatment of autism spectrum disorders may be limited to a member through 18 years of age and may be subject to a maximum annual benefit as follows: (i) For a covered member through 6 years of age, $50,000.00; (ii) For a covered member from 7 years of age through 12 years of age, $40,000.00; and (iii) For a covered member from 13 years of age through 18 years of age, $30,000.00.

Minnesota

Effective January 1, 2014, requires all health plans issued to a large employer, the state employee group insurance program must provide coverage for the diagnosis, evaluation, multidisciplinary assessment, and medically necessary care of children under 18 with autism spectrum disorders. Treatment includes speech therapy. Children enrolled in medical assistance will receive early intensive intervention for an autism spectrum disorder diagnosis.

Missouri

Requires all group health benefit plans that are delivered, issued for delivery, continued, or renewed on or after January 1, 2011, to provide coverage for the diagnosis and treatment of autism spectrum disorders to the extent that such diagnosis and treatment is not already covered by the health benefit plan. Treatment for autism spectrum disorders, care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist, include: psychiatric care; psychological care; habilitative or rehabilitative care, including applied behavior analysis therapy; therapeutic care (including services provided by licensed speech therapists, occupational therapists, or physical therapists); and pharmacy care.

Montana

Requires each group disability policy, certificate of insurance, or membership contract that is delivered, issued for delivery, renewed, extended, or modified in this state must provide coverage for diagnosis and treatment of autism spectrum disorders for a covered child 18 years of age or younger. Treatment includes: habilitative or rehabilitative care that is prescribed, provided, or ordered by a licensed physician or licensed psychologist, including but not limited to professional, counseling, and guidance services and treatment programs that are medically necessary to develop and restore, to the maximum extent practicable, the functioning of the covered child; medications prescribed by a physician; psychiatric or psychological care; and therapeutic care that is provided by a speech-language pathologist, audiologist, occupational therapist, or physical therapist licensed in this state. Coverage for treatment of autism spectrum disorders under this section may be limited to a maximum benefit of:

Nebraska

Effective July 1, 2014, requires any individual or group sickness and accident insurance policy or subscriber contract delivered, issued for delivery, or renewed in this state and any hospital, medical, or surgical expense-incurred policy, except for policies that provide coverage for a specified disease or other limited-benefit coverage, and (b) any self-funded employee benefit plan to the extent not preempted by federal law, including any such plan provided for employees of the State of Nebraska, to coverage for the screening, diagnosis, and treatment of an autism spectrum disorder in an individual under twenty-one years of age. Treatment includes: (i) Behavioral health treatment; (ii) Pharmacy care; (iii) Psychiatric care; (iv) Psychological care; and (v) Therapeutic care. Therapeutic care means a service provided by a licensed speech-language pathologist, occupational therapist, or physical therapist.

Nevada

Effective January 1, 2011—Requires an individual health benefit plan to provide an option of coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders for persons covered by the policy under the age of 18 or, if enrolled in high school, until the person reaches the age of 22. Treatment of autism spectrum disorders must be identified in a treatment plan and may include medically necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care, behavior therapy or therapeutic care (including services provided by licensed or certified speech pathologists, occupational therapists and physical therapists).

New Hampshire

Requires insurance coverage for diagnosis and treatment of pervasive developmental disorder or autism for all group policies, contracts, and certificates issued or renewed on or after January 1, 2011. Treatment includes: professional services and treatment programs, including applied behavioral analysis; prescribed pharmaceuticals subject to the same terms and conditions of the policy as other prescribed pharmaceuticals; direct or consultative services provided by a licensed professional including a licensed psychiatrist, licensed advanced practice registered nurse, licensed psychologist, or licensed clinical social worker; and Services provided by a licensed speech therapist, licensed occupational therapist, or licensed physical therapist.

New Jersey

Requires specified health insurance policies and health benefit plans to provide benefits for treatment of autism or other developmental disability. Coverage shall include: medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. The maximum benefit amount for a covered person in any calendar year through 2012 shall be $37,080.

New Mexico

Requires specified health insurance policy, health care plan or certificate of health insurance shall provide coverage to an eligible individual who is nineteen years of age or younger, or an eligible individual who is twenty-two years of age or younger and is enrolled in high school, for:

well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and

New York

Requires every policy which provides physician services, medical, major medical or similar comprehensive-type coverage to provide coverage for the screening, diagnosis and treatment of autism spectrum disorder. Coverage includes, therapeutic care, which is habilitative or nonrestorative, provided by a licensed or certified speech therapist.

North Carolina

Requires health benefit plans to provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. Coverage includes therapeutic care, which includes services provided by a licensed speech-language pathologist.

Ohio

Governor John Kasich signed the Autism Insurance Directive in December 2012,which would include autism services in the Essential Health Benefits package for plans in Ohio provided under the Affordable Care Act and to state employees as part of their employee health insurance benefits. The coverage includes 20 visits per year of speech and language therapy.

Oklahoma

Requires all plans issued or renewed on or after November 1, 2016, a health benefit plan and the Oklahoma Employees Health Insurance Plan to provide coverage for the screening, diagnosis and treatment of autism spectrum disorder in individuals less than nine (9) years of age, or if an individual is not
diagnosed or treated until after three (3) years of age, coverage shall be provided for at least six (6) years, provided that the individual continually and consistently shows sufficient progress and improvement as determined by the health care provider. Treatment covers "therapeutic care" provided by
licensed or certified speech therapists, occupational therapists or physical therapists.

Oregon

Requires health benefit plans to cover for a child enrolled in the plan who is under 18 years of age and who has been diagnosed with a pervasive developmental disorder (including autism) all medical services, including rehabilitation services, that are medically necessary and are otherwise covered under the plan. Rehabilitation services is defined as physical therapy, occupational therapy or speech therapy services to restore or improve function.

Note: 743A.190 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein.

Pennsylvania

Requires a health insurance policy or government program to provide coverage for individuals less than 21 years of age for the diagnostic assessment and treatment of autism spectrum disorder. Treatment includes: pharmacy care, psychiatric care, psychological care, rehabilitative care and therapeutic care (includes services provided by speech language pathologists, occupational therapists or physical therapists) that is medically necessary and prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner. Coverage provided under this section by an insurer shall be subject to a maximum benefit of $37,080 per year and is not subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorders.

Rhode Island

Requires every group health insurance contract, or every group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state, by any health insurance carrier, on or after January 1, 2012, to provide coverage for autism spectrum disorders. These provisions are not subject to the Small Employer Health Insurance Availability Act, or the Individual Health Insurance Coverage Act. Benefits include coverage for applied behavior analysis, physical therapy, speech therapy and occupational therapy services for the treatment of Autism spectrum disorders. The benefits will continue until the covered individual reaches the age of fifteen.

South Carolina

Requires a health insurance plan to provide coverage for the treatment of autism spectrum disorder. To be eligible for benefits and coverage, an individual must be diagnosed with autistic spectrum disorder at age eight or younger. The benefits and coverage provided must be provided to any eligible person under sixteen years of age.

Note: Speech language services are not specifically defined in the statute. Coverage is "limited to treatment that is prescribed by the insured's treating medical doctor in accordance with a treatment plan." Although behavioral therapy is not specifically defined, the statute does set out a cap of $50,000 per year for coverage of behavioral therapy.

South Dakota

Requires all individual and group health insurance policies, contracts and certificates issued by health carriers and self-funded nonfederal governmental plans with the exception of the state employee health plan sponsored by the State of South Dakota to provide coverage for treatment of autism spectrum disorder. Treatment means evidence-based care which is prescribed or ordered for a person diagnosed with an autism spectrum disorder by a licensed physician or psychologist, including: behavioral health treatment; pharmacy care; and therapeutic care. Therapeutic care is not further defined.

Texas

Requires a health benefit plan to provide coverage to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis until the enrollee completes nine years of age. If an enrollee who is being treated for autism spectrum disorder becomes 10 years of age or older and continues to need treatment, this does not preclude coverage of treatment and services. Treatment may include services such as: evaluation and assessment services; applied behavior analysis; behavior training and behavior management; speech therapy; occupational therapy; physical therapy; or medications or nutritional supplements used to address symptoms of autism spectrum disorder.

Vermont

Requires a health insurance plan to provide coverage for the diagnosis and treatment of autism spectrum disorders, including applied behavior analysis supervised by a nationally board-certified behavior analyst, for children, beginning at 18 months of age and continuing until the child reaches age six or enters the first grade, whichever occurs first. Treatment includes: habilitative or rehabilitative care; pharmacy care; psychiatric care; psychological care; and therapeutic care (includes services provided by licensed or certified speech language pathologists, occupational therapists, physical therapists, or social workers), if the physician or psychologist determines the care to be medically necessary. The provisions go into effect on or after July 1, 2011, on such date as a health insurer offers, issues, or renews the health insurance plan, but in no event later than July 1, 2012.

Virginia

Requires health insurance plans issued or renewed after January 1, 2012, to provide coverage for the diagnosis and the treatment of autism spectrum disorder in individuals from age two through age six. An individual who is being treated and continues to need treatment for autism spectrum disorder and becomes seven years of age or older is not precluded from coverage of treatment and services. Treatment shall be determined by a licensed physician or a licensed psychologist to be medically necessary, and includes: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care (which includes services provided by licensed or certified speech therapists, occupational therapists, physical therapists, or clinical social workers), and (vi) applied behavior analysis when provided or supervised by a board certified behavior analyst who shall be licensed by the Board of Medicine. Certain insurers may be exempt from requirements for 1 year and may reapply for the exemption yearly.

Washington

As the result of litigation, Washington state Insurance Commissioner, Mike Kreidler, directed all state-regulated private health plans to provide coverage for medically necessary treatment of autism, including coverage of speech, occupational, physical and ABA therapy. The order also covers new health plan sold through the state healthcare marketplace created under the Affordable Care Act.

West Virginia

Requires health insurance plans issued or renewed after January 1, 2012, to include coverage for diagnosis, evaluation and treatment of autism spectrum disorder in individuals aged eighteen months to eighteen years. The individual must be diagnosed with autism spectrum disorder at age 8 or younger. Treatment shall be determined to be medically necessary by a licensed physician or licensed psychologist.

Note: Speech language services are not clearly defined in the statue. However, applied behavioral analysis is specifically included and coverage limitations are set out.

Wisconsin

Requires every disability insurance policy, and every self−insured health plan of the state or a county, city, town, village, or school district, to provide coverage for an insured of treatment for the mental health condition of autism spectrum disorder if the treatment is prescribed by a physician and provided by any of the following who are qualified to provide intensive−level services or nonintensive−level services: a psychiatrist; a psychologist; a social worker; a paraprofessional working under the supervision of a psychiatrist, psychologist or social worker; a professional working under the supervision of an outpatient mental health clinic; a speech−language pathologist; or an occupational therapist. The coverage required shall provide at least $50,000 for intensive−level services per insured per year, with a minimum of 30 to 35 hours of care per week for a minimum duration of 4 years, and at least $25,000 for nonintensive−level services per insured per year.

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